Written by: Bryetta Calloway
When patients arrive at Grady with a suspected diagnosis of placenta accreta spectrum (PAS), many bring more than medical risk; they bring profound fear.
Some have been told at an outside hospital that they might hemorrhage, lose their uterus, or even face life-threatening complications. Others have been advised to travel far from home to find a center equipped to manage the complexity of their case. For many, the first moments inside Grady’s Maternal–Fetal Medicine (MFM) service are filled with questions, uncertainty, and the weight of a pregnancy suddenly marked as high-risk.
“Many patients who come to us are scared to death,” says Dr. Hillary Hosier, MFM specialist at Grady and one of the physicians helping shape the growing Placenta Accreta Clinic. “When someone has been told, ‘You might die,’ or ‘You may need a hysterectomy,’ it completely transforms how they experience their pregnancy. We try to help them feel safe so that they can remember that this delivery is still about the birth of their baby, not just the time that they could have died.”
Grady’s developing PAS program is designed precisely for moments like these, pairing evidence-based multidisciplinary care with trauma-informed counseling and education. Built on foundational work begun by Dr. Marisa Young and Dr. Britton Chahine , who established the program years earlier, the clinic is rapidly becoming a regional model for coordinated, high-acuity perinatal care.
Understanding Placenta Accreta Spectrum
Placenta accreta spectrum describes a group of conditions in which the placenta grows too deeply into—or even beyond—the uterine wall. It ranges from accreta (placenta adherent to the endometrium) to increta (invasion into the myometrium) and percreta (penetration beyond the uterus into surrounding organs such as the bladder or pelvic sidewall).
The condition is rising nationally, due in part to increasing cesarean delivery rates. While prior C-sections and uterine surgeries are the most recognized risk factors, PAS can rarely occur even in the absence of surgical history.
The underlying pathophysiology is straightforward but consequential. In a typical menstrual cycle, the endometrium thickens and sheds cyclically. Surgical disruption, however, may create areas in which the endometrial lining is absent. When a pregnancy implants over that denuded or weakened area, the placenta can attach directly to the uterine wall with no normal separation plane at delivery, setting the stage for a potentially life-threatening hemorrhage.
The principal maternal risks include:
- Severe hemorrhage
- Injury to surrounding structures such as the bladder, ureters, bowel, ovaries and vasculature
- Need for cesarean hysterectomy
- Need for significant blood transfusion, intubation, and ICU admission
- Post-operative infections, blood clots, and delayed surgical complications
- Postpartum trauma, mood disorders, and lactation challenges
For these reasons, national data strongly support management at centers with dedicated teams, standardized protocols, and access to surgical subspecialists—exactly the model Grady is working to expand.
Why Grady Memorial Hospital? A Regional Perinatal Center Positioned for High-Acuity Care
As the Regional Perinatal Center for Atlanta, Grady is uniquely positioned to lead a program of this complexity. The hospital cares for a large, diverse population with high-acuity needs and maintains the full spectrum of subspecialty support required for placenta accreta spectrum care. Its infrastructure—spanning maternal–fetal medicine, gynecologic oncology, trauma surgery, interventional radiology, OB anesthesia, neonatology, blood bank services, and perinatal psychiatry enables rapid, coordinated responses when complications are anticipated or encountered.
These embedded resources, combined with Grady’s longstanding mission to provide comprehensive care for medically vulnerable populations, make it a natural home for a multidisciplinary PAS program. The institution’s volume, patient diversity, and collaborative culture offer a robust foundation for ongoing program growth, innovation, and learner training.
The Architecture of Multidisciplinary Care
A significant portion of the clinic’s work begins long before the operating room. Many patients are referred after concerning imaging at outside hospitals, or simply because they have multiple risk factors.
Part of the clinic’s mission is diagnostic refinement. “Sometimes patients come to us absolutely terrified; however, after reviewing their cases, we end up having a much lower suspicion for PAS,” Hosier says. “In those cases, we individualize the plan for their delivery at Grady. Even with a lower concern for PAS, often the primary providers or hospitals are unable to offer delivery due to lack of resources in the event of surgical complication or hemorrhage. Because of this, we still plan their care at Grady with options for contingency plans, but part of our job is helping them understand their true risk based on the clinical scenario and expert imaging.”
The Grady PAS program's strength lies not in any single innovation but in its systematic coordination of multiple specialties. At the program's heart is a monthly multidisciplinary conference where every case undergoes a thorough review, both pre-operatively for planning and post-operatively to confirm final pathology and review opportunities for improvement.
These conferences, run by Maternal-Fetal Medicine fellows as part of their education, bring together an impressive array of expertise. The team reviews imaging (both ultrasound and MRI), discusses surgical planning, and determines exactly what teams and supplies need to be in the operating room for each case. Fellows select key images and relevant literature, turning each conference into both a planning session and an educational opportunity for the residents and PAS team members.
"We talk with everybody about what we think the safest delivery plan would be for each individual patient and who needs to be in the room standing at the table for delivery," Dr. Hosier explains. The "everybody" is extensive: maternal-fetal medicine, OB/GYN surgeons, gynecologic oncology, NICU teams (since most PAS deliveries are preterm), urology, interventional radiology, trauma surgery, OB anesthesia, blood bank, and pathology.
Each specialty plays a crucial role. Urologists can perform cystoscopy and place ureteral stents to prevent injury during surgery, since the ureters pass dangerously close to the surgical field. Interventional radiology may perform embolization procedures to control bleeding. In the most complex cases, trauma surgeons place a REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta). This catheter inflates a balloon in the aorta to temporarily stop blood flow to the pelvis during the most hemorrhagic portions of surgery.
"It's a large and diverse team of providers," Dr. Hosier acknowledges, but the complexity of these cases demands nothing less.
Education Embedded in Clinical Excellence
The program's educational mission permeates every aspect of care. Fellows don't just attend the monthly conferences; they lead them, developing critical skills in case presentation, image interpretation, and multidisciplinary coordination. Residents are the primary team managing these patients' hospital care and are routinely included in surgeries, with Dr. Hosier sometimes including two residents in particularly complex cases.
Twice yearly, the team holds combined conferences with the Complex Family Planning division, recognizing that cesarean scar ectopic pregnancies—when implantation occurs in a prior cesarean scar—represent an early point on the PAS spectrum. These sessions ensure that residents and fellows understand the full continuum of these conditions, from early pregnancy complications to third-trimester surgical emergencies.
This educational integration serves a dual purpose: preparing the next generation of specialists while ensuring that current care benefits from constant questioning and review. "We're constantly evolving protocols, keeping up with the literature, and learning from our own cases even as we go," Dr. Hosier notes.
Individualized Surgical Planning and Fertility Considerations
While cesarean hysterectomy remains the standard treatment for placenta accreta spectrum, the Grady team recognizes that each patient brings unique circumstances and desires to their care. Dr. Hosier and her colleagues carefully evaluate whether certain patients might be candidates for fertility-preserving approaches, particularly when future childbearing holds deep personal or cultural significance.
"For some patients, future childbearing is deeply important," Hosier explains. "We're thoughtful about who might be a safe candidate for trying to salvage their uterus." This individualized approach requires a delicate balance weighing maternal safety against the profound desire to preserve fertility.
The counseling process itself reveals important gaps in understanding. Many patients don't initially realize that a hysterectomy typically preserves the ovaries and hormonal function—a distinction that varies significantly across regional and cultural contexts. The team must navigate these conversations with sensitivity, addressing not only the immediate loss of childbearing capacity but also the theoretical possibilities of egg retrieval and gestational carriers, while acknowledging that such options remain financially out of reach for many patients.
"I think it's really hard for some patients to celebrate the birth of their baby when they're still mourning the loss of part of their identity," Hosier reflects. These conversations underscore a fundamental truth about PAS management: while surgical excellence is essential, the care these patients need extends far beyond the operating room. It encompasses their hopes for future children, their sense of self, and their ability to find joy in the child they're delivering, even as they grieve possibilities that may be lost.
This attention to the whole person—their fears, hopes, and identity—transforms what could be a purely clinical interaction into genuinely compassionate care.
The Psychological Landscape: Trauma, Identity, and Support
Perhaps the program's most innovative aspect is its explicit attention to psychological trauma and patient experience. Dr. Hosier speaks passionately about the emotional landscape these patients navigate: young, healthy people suddenly confronting mortality, potential infertility, and separation from support systems when traveling for care.
"These patients have significant PTSD," she emphasizes. Currently, she provides all patients with resources from the National Accreta Foundation, refers them to accessible mental health platforms, and connects them with Grady's perinatal psychiatrist. But her vision extends further.
"My dream would be to have one of our patients come back to do training to become a patient guide or peer navigator or ‘accreta doula’," she explains, envisioning trained peer supporters with prior personal insight who could accompany patients through their journey from diagnosis through recovery.
This attention to psychological well-being isn't an add-on; it's integral to the program's philosophy.
Training the Next Generation: A High-Impact Learning Environment
The Grady Placenta Accreta Spectrum Program demonstrates how a regional referral center can build excellence through systematic coordination, educational integration, and attention to the full spectrum of patient needs. By combining surgical expertise with psychological support, diagnostic precision with compassionate care, and standardized protocols with individualized decision-making, the program offers a model that other centers might adapt to their own contexts.
For prospective residents and fellows, the program offers unparalleled exposure to complex obstetric surgery within a genuinely multidisciplinary framework. For collaborating faculty, it presents opportunities for research collaboration and quality improvement initiatives. For alumni who trained at Grady or Emory, it represents both continuity with the institution's tradition of serving complex patients and evolution toward increasingly sophisticated, coordinated care.
As referrals continue to arrive from across Georgia and beyond, the team remains focused on its dual mission: delivering the best possible care to each patient while advancing the field's understanding of how to manage these challenging cases. In Dr. Hosier's words, they're working to ensure that even in the face of one of obstetrics' most serious complications, patients can experience what should be a fundamental truth—that this is still, first and foremost, about the birth of their baby.
The Grady Placenta Accreta Spectrum Program accepts referrals from throughout Georgia and surrounding states. Healthcare providers seeking consultation or referral information should contact the Maternal-Fetal Medicine Division. The program continues to welcome collaboration opportunities for research and quality improvement initiatives.